My mom has been on a Medicare Advantage plan for a few years. When we moved states about 6 years ago, it was the only plan that included one of her medications on the formulary.
The drug is Stelara, and she self-administers it at home.
I’m trying to enter Stelara on medicare.gov, but the site won’t accept the dose frequency correctly. She takes one shot every 84 days. I select the 90mg/ml prefilled syringe and choose the 1ml package (the only option), then set the quantity to 1 “Every 3 months.”
But every plan shows the drug cost for 2025 will be $133,000, and none reflect the $2,000 cap for 2025.
When I check the plan details, I do see a note saying, “For 2025, you won’t pay more than $2,000 out-of-pocket for covered Part D drugs,” but Stelara is still listed at $33k per shot with a footnote saying:
“This plan does not cover this drug at the selected frequency, so the price shown represents the full cash price.”
Is there a way to get the medicare.gov site to show accurate costs for Stelara?
The only workaround I found is to set it as 1 syringe per month instead of every 3 months. That at least reflects the $2,000 cap. Is this really the only way to do it, even if it’s not accurate?
I’m seeing that most plans in my area cover the 45mg/0.5ml x 2 each month. If it’s covered at a higher frequency, you’re good. She doesn’t have to fill it that often, just when needed. The plan won’t deny her just because she doesn’t fill it monthly.
@Jai
It’s probably a coding issue on the site. Ideally, they should make lower frequency options show as covered if higher frequency is already approved. It’s odd that it’s marked as uncovered just because the exact frequency isn’t explicitly listed.
@Micah
Thanks. We’ll just enter it as one per month and verify everything else looks okay. We’re debating switching from AARP/UHC to Aetna, which is rated higher. But we haven’t had any issues with UHC, so…
@Jai
FWIW, we’ve been with AARP UHC Advantage for years, across two different regions in Texas. No issues with providers being in-network, but we do stick to major hospital groups.
Hal said: @Jai
FWIW, we’ve been with AARP UHC Advantage for years, across two different regions in Texas. No issues with providers being in-network, but we do stick to major hospital groups.
Thanks! We’re not in Texas anymore (despite my username), but we also use a major hospital group where we are now.
I’ve heard some concerns about UHC not paying providers on time, but so far, all our doctors still work with them… so I’m not sure.
@Jai
Just double-check that her providers are in-network with Aetna if you consider switching. If they are, it’s really up to your preference.
I’d also look at things like the annual out-of-pocket max and any extra benefits (like dental or OTC coverage). But definitely start with the most important—providers and medications.
@Micah
Yes, we always make sure her critical meds are on the formularies and then check the providers! The extras come last.
We originally switched to an Advantage plan because, when we moved, Stelara wasn’t on a Part D formulary. Since then, it’s been on the Advantage plan lists.
